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The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
1
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
BULLETIN
Docket No.: INS No. 16-010-AB
TO: All New Hampshire Licensed Health Insurance Companies, Health
Maintenance Organizations, Fraternal Benefit Societies and
Third Party Administrators
FROM: Roger A. Sevigny
Insurance Commissioner
DATE: March 30, 2016
RE: Supplemental Data Request
Table of Contents
Background ..................................................................................................................... 2
Changes in Requirements .............................................................................................. 3
Purpose of Changes ........................................................................................................ 3
Definitions ....................................................................................................................... 4
Applicability .................................................................................................................... 8
Exemptions ..................................................................................................................... 8
De Minimis Exemption ................................................................................................... 9
Creditable Coverage ....................................................................................................... 9
Due Date ......................................................................................................................... 9
Fines .............................................................................................................................. 10
Tabulation Methods and Issues ................................................................................... 10 Tabulation of Information ...................................................................................................................................... 11 Tabulation Issues – Multiple Carriers.................................................................................................................. 12 Tabulation Issues – Geographic Location ........................................................................................................... 13 Acceptable Methods for Estimating Data ........................................................................................................... 13 Acceptable Methods for Submission .................................................................................................................... 14 Data Reconciliation ................................................................................................................................................. 14
Confidentiality .............................................................................................................. 15
Attachment A Supplemental Data Request Specifications ......................................... 15 Transmittal ................................................................................................................................................................ 15 Main Data Collection ............................................................................................................................................... 17
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
2
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Limited Data Collection .......................................................................................................................................... 32 Stop Loss Data Collection ....................................................................................................................................... 36 Data Checks ............................................................................................................................................................... 41 Data Reconciliation ................................................................................................................................................. 43 Summary Tables ....................................................................................................................................................... 43
Attachment B-1 ............................................................................................................. 45
Attachment B-2 ............................................................................................................. 46
Attachment C ................................................................................................................ 47
Attachment D ................................................................................................................ 51
Attachment E ................................................................................................................ 52
Attachment F ................................................................................................................ 57
Background
Pursuant to RSA 400-A:36 and other provisions of Title XXXVII, the Insurance
Commissioner has the authority to prescribe the format and content of financial and
other reports filed by licensed insurers in New Hampshire. The reports submitted
by licensed carriers and other entities are required to evaluate the financial
solvency of carriers operating in New Hampshire (NH) as well as to understand the
characteristics of New Hampshire’s insurance markets.
In 2002, the Commissioner implemented an annual statement supplemental
reporting requirement with respect to health insurance coverage. See Bulletin INS
No. 02-001-AB.
The New Hampshire General Court, during its 2003 general session, adopted
Senate Bill 110, now codified at RSA 420-G:14-a, which placed further health
insurance data collection responsibilities on the Department. On March 22, 2006,
the approval of Senate Bill 369 amended RSA 420-G:14-a and broadened the
authority of the Commissioner to collect information related to the supplemental
report.
This bulletin is issued to update the information requested by the Department. The
requirements for submitting data for the supplemental data request are very
similar to the requirements for submitting claims data according to INS 4000.
Carriers should confirm that they have applied the same reporting criteria to
both submissions. If the same reporting criteria are not applied, the carrier/Third
Party Administrator shall identify and explain the differences.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
3
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
This bulletin repeals and replaces INS No. 15-010-AB.
Changes in Requirements
The following is a high-level description of changes made to this bulletin from the
previous bulletin. Do not rely on this list exclusively; read the entire bulletin to
ensure compliance with reporting requirements.
• Two additional fields for Specialty prescription drugs have been added. One
for Specialty Coinsurance and one for Specialty Copay.
• The Plan ID field has been modified to identify Cost Sharing Reduction
plans. This field will allow us to identify plans that are sold off Exchange, on
Exchange, and the level of cost sharing reduction, where applicable. The
definition of Plan ID is the Standard Component plus the Variant1. See the
CSR tab for instructions and details.
• The Exchange indicator has been expanded to collect information about the
network. See the “Exchange and Network” tab for instructions and details.
• An additional worksheet named “Summary Tables” has been added. This
worksheet contains three tables that summarize the data provided in the
Main, Limited and Stop-Loss Worksheets. There is a Refresh button which
updates the three tables. Please review these summaries prior to submitting
the template.
• The Data Reconciliation Worksheet has been modified to eliminate the
reconciliation with the NAIC Supplemental Health Care Exhibit.
• The de minimis reporting requirements are aligned with INS 4005.022 and
are unchanged from last year’s bulletin.
• This year’s bulletin requests one submission of calendar year 2015 data.
• The due date for the submission of data is June 30, 2016.
• The primary point of contact for questions related to this submission is Don
Gorman at Gorman Actuarial, Inc. (Email: [email protected])
Purpose of Changes
The changes to this year’s bulletin will contribute to the NHID’s efforts to gather
additional data required by the New Hampshire Legislature’s 2014 Senate Bill 345,
now codified as RSA 420-G:14-a, VI. In addition, these changes are intended to
better streamline data submission for carriers and align the Supplemental Data
1 https://www.cms.gov/CCIIO/Resources/Data-Resources/Downloads/2014-Plans-Attributes-Data-Dictionary.pdf
2 http://www.gencourt.state.nh.us/rules/state_agencies/ins4000.html
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
4
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Request with other data requests that the NHID issues to carriers each year.
Definitions
(a) “Actuarial Value” – For the purposes of this report, the Actuarial Value
will be the Minimum Value measure as outlined in Section 1302
(d)(2)(C) of the Affordable Care Act. Beginning in 2014, insurers and
employers or unions with self-insured plans must report information to
the IRS for each individual covered under a health insurance plan that
provides minimum coverage. This information will be used by the IRS
to determine whether individuals who purchase insurance on the
exchanges will be eligible for a premium tax credit. The minimum
value is defined as the percentage of the total allowed costs of benefits
provided under a group health plan or health insurance coverage. In
accordance with the HHS regulations there are several options for
determining the Minimum Value:
• Determine Minimum Value figure using the most recent version of
the publically available Minimum Value Calculator Excel model
tool which can be downloaded from the CMS website3. The
Department of Health and Human Services has published guidance
titled “Minimum Value Calculator Methodology” which is also
available on the website. This guidance provides a detailed
description of the data underlying the MV Calculator and the
calculator’s methodology.
• Determine Minimum Value figure through any safe harbor
established by HHS and IRS.
• If the plan design is incompatible with the Minimum Value
Calculator or Safe Harbor Plan, the Minimum Value figure may
be determined through an actuarial certification from a member
of the American Academy of Actuaries.
For each set of reported coverage options, e.g. each benefit plan, the
carrier shall include the Minimum Value figure calculated in
accordance to one of the three options mentioned above. The Minimum
Value Calculator can be used for a wide variety of health plan designs;
3 Currently at this link: http://www.cms.gov/cciio/resources/regulations-and-guidance/index.html
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
5
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
however, it is possible some benefit plan designs may not fit into the
calculator. In circumstances where this is the case, and the minimum
value from the safe harbor or actuarial certification is not readily
available, a reasonable estimate based on comparison to similar plan
designs may be reported if the carrier receives prior approval from the
NHID. If a carrier used a method other than the Minimum Value
Calculator, the alternate method that was used must be disclosed and
described in the notes section of the report submittal form along with
documentation of prior approval, if applicable.
Please do not provide figures based on the Actuarial Value
Calculator. The Actuarial Value Calculator uses different
population base and different continuance tables than the Minimum
Value Calculator. The results from the two calculators will be
slightly different. For the purposes of this report and stable
comparison across coverage segments and carriers, the Minimum
Value Calculator must be used.
This minimum value as described above is the “actuarial value.”
(b) “Blanket health insurance” is as defined under RSA 415:18, I-a and
means that form of accident and health insurance that is not "health
coverage'' under RSA 420-G:2, IX, that does not require individual
applications from covered persons, and that does not require a carrier
to furnish each person with a certificate of coverage.
(c) “Certificate holder” shall have its standard language meaning for
insurance writers and their written coverage. For employer-sponsored
group coverage, the employee or subscriber shall be the certificate
holder. For individual coverage, the policyholder shall be the
certificate holder. For other types of group coverage, the certificate
holder shall mean the person who is the principal insured.
(d) “Claims Incurred” shall reflect total medical expense for services
received by the covered members in the reporting class during the
calendar year for which the data are being reported. Note that total
claims are based on an accrual basis for calendar year, and are equal
to the sum of (i) claims incurred and paid, (ii) claims incurred and
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
6
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
unpaid, and (iii) other payments and credits (see Attachment A for
definitions of these sub-components). All claims with a date of service
during the reporting year are to be included as claims paid in this
field. If necessary, actuarial completion factors should be used to
estimate incurred claims and should be based on when the carrier
extracts the data for the Supplemental Data Request. Incurred
claims should be consistent with what is reported in Part 1, Line 5 of
the NAIC Supplemental Health Care Exhibit, allowing for variances
due to any restatement of unpaid claims with additional paid claim
runout. Additional detail regarding how to report Claims Incurred
can be found in Attachment A.
(e) “Covered lives” or “members” shall include all individuals, employees
and dependents for which the health carrier or third-party
administrator has an obligation to adjudicate, pay or disburse claim
payments. Data submission requirements apply to all members who
receive services under a policy sold to a New Hampshire employer
with a business location in New Hampshire, or to a resident of New
Hampshire who receives services under a policy issued by the carrier
or services by the third party administrator. For employer-sponsored
group coverage, covered lives would include certificate holders and
their dependents.
(f) “Creditable coverage” shall have the same meaning as defined in RSA
420-G:2, III.
(g) "Data" means factual information used as a basis for calculation or
measurement.
(h) "Database" means a collection of data organized especially for search
and retrieval.
(i) “Eligible Employee” shall have the same meaning as defined in INS
4100, specifically INS 4103.03 (g) for the Small Group market, INS
4104.03 (i) for the Large Group market, and 4105.03 (h) for the Stop
Loss market.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
7
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
(j) "Health carrier" shall mean any licensed insurance company with a
Paragraph 4 authorization on its New Hampshire license. Licensed
entities include Life Insurance Companies, Property & Casualty
Insurance Companies, Health Maintenance Organizations, Fraternal
Benefit Societies and Nonprofit Health Service Corporations. Health
carrier shall also include Third Party Administrators (TPAs).
(k) “Policy” shall have its standard language meaning for insurance
writers. For employer-sponsored group coverage, where the coverage
is written directly for the employer’s benefit plan, the employer shall
be considered the policyholder. A policy that is issued in New
Hampshire shall include any policy that provides coverage to the
employees of a New Hampshire employer that has a business location
in New Hampshire. An employer's branch location in New Hampshire
shall be considered a New Hampshire employer, and the carrier/TPA
shall submit data for all members who are employed at that branch
location. For employer-sponsored group coverage, issued to a qualified
association trust, each member employer shall be considered a
separate policyholder. For all association business, each member
employer shall be considered as a separate policyholder. TPAs shall
report policyholders in a like manner.
(l) “Premium” shall be calculated as “earned” premium, or the total
amount of premium from policyholders to provide insurance coverage
during the reporting year. Earned premium = premiums collected +
change in due and uncollected – change in unearned and advance
premium. This should include advance payments of the premium tax
credit. If premium is collected prior to January 1, to provide insurance
coverage during the reported calendar year, then it must be included
in this column. The Commissioner may approve the use of a
reasonable proxy upon the carrier’s provision of documentation
demonstrating that the use of the same does not materially distort the
carrier’s data submission. For TPAs, premium shall mean the funds
collected from contracted accounts to provide for all claims and
expenses associated with the administration of the employer’s benefit
plan. Additional detail regarding how to report Premium can be found
in Attachment A.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
8
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
(m) “Situs” of a policy shall be defined as the jurisdiction in which the
policy is issued or delivered as stated in the policy. For employer
business issued through a qualified association trust, the situs shall be
based on the location of each member employer. The intent of this
definition is to be consistent with the instructions for the NAIC
Supplemental Health Care Exhibit. Carriers should apply the same
consideration when determining situs for this report as they do for the
Supplemental Health Care Exhibit. TPAs shall determine situs of
their contracts in a like manner.
(n) “Subcontractor” shall be defined as a vendor or contractor who
manages carved out categories of services such as mental health
services or pharmacy services. Since the subcontractor may be required
by the carrier/TPA to satisfy state reporting requirements for the
subcontracted services, the Department needs to understand what
carriers or TPAs are including data from a subcontractor in order to
avoid double counting multiple submissions. The carrier/TPA is
ultimately responsible for a complete submission without duplicate
data, and is most often better served by submitting one filing rather
than relying on the subcontractor to fulfill the carrier/TPA’s
obligations.
Applicability
All carriers licensed to write accident and health insurance in the state of New
Hampshire and meeting minimum thresholds must submit Supplemental Data
Request data. A carrier is licensed to write accident and health insurance if it has
a Paragraph 4 authorization on its New Hampshire license. A licensed or
registered Third Party Administrator (TPA) must submit Supplemental Data
Request data only if it exceeds the de minimis exemption criteria described below.
Covered lives/members are individual members eligible to have claims paid for
them, not accounts. Membership is determined based on the definition of covered
lives as defined herein, and will include New Hampshire residents with an account
that is located out of state.
Exemptions
All carriers and TPAs must submit Supplemental Data Request data unless they
meet the de minimis exemption described below.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
9
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
De Minimis Exemption
Carriers and third-party administrators are not required to submit data if they
meet the following criteria:
For carriers that do not offer any products on the health insurance exchange for
residents of New Hampshire, and that did not cover more than 9,999 members
in New Hampshire at any point in any coverage class (medical or pharmacy)
during the immediately preceding calendar year; or
For third-party administrators that did not cover more than 9,999 members in
New Hampshire at any point in any coverage class (medical or pharmacy)
during the immediately preceding calendar year.
Carriers and third-party administrators shall perform the de minimis
calculation at the entity level, i.e., the level at which major governance decisions
are made under a senior leadership team, regardless of the number of
companies operating under separate corporate divisions.
Creditable Coverage
A carrier writes creditable coverage when it issues a policy for coverage that meets
the definition of creditable coverage in RSA 420- G:2, III. A TPA administers
creditable coverage when it provides administrative services to either an insurer or
an employer that has assumed the risk for an employer-sponsored or other
sponsored plan that provides creditable coverage. In addition, carriers writing stop-
loss or group excess loss insurance to employers whose self-insured plans meet the
definition of creditable coverage must submit data. Throughout this bulletin,
references to writing carriers shall include all of the activities referenced in this
paragraph. All of these carriers and TPAs must submit the policy data tabulated as
prescribed.
Stop loss and group excess coverage shall be reported, both by carriers issuing
stand-alone stop loss coverage and carriers issuing stop loss coverage to the
employer groups for which they administer the self-insured health benefits.
Due Date
Carriers and TPAs must submit data summarizing the carrier’s business from the
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
10
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
immediately preceding calendar year. The data submission due June 30, 2016
shall summarize the carrier’s business for the preceding calendar year, ending on
December 31, 2015. This annual reporting requirement shall continue in
perpetuity unless and until explicit revocation by the NHID.
Upon receiving a report submission, Gorman Actuarial will confirm receipt by e-
mail. The submission will be reviewed for completeness. Insurance carriers and
TPAs are required to submit a filing which satisfies NHID standards for
completeness and compliance by June 30, 2016. Incomplete or non-compliant filings
on June 30, 2016 will be subject to an administrative fine.
Fines
Fines will be assessed for failure to meet the submission deadline of June 30, 2016,
for filing an incomplete template, or for filing data that is inaccurate. Fines shall
accrue on a daily basis. There will be no grace period to achieve compliance. All
reports are expected to be complete and accurate submissions on the date of
submission.
Tabulation Methods and Issues
Data shall be tabulated in three separate, mutually exclusive data collections: (1)
the Main Data collection, (2) the Limited Data collection, and (3) the Stop Loss Data
collection. The Main Data collection shall include data for all members who receive
services under a policy (whether individual or employer-sponsored) with a New
Hampshire situs or through a contract with a New Hampshire situs issued by a
third party administrator. The Limited Data collection shall include data for all
New Hampshire residents, or members who have a work location in New
Hampshire (e.g. an out-of-state employer with a branch location in New
Hampshire), with a policy that does not have a New Hampshire situs. The
carrier/TPA shall submit data for all members who are employed at the New
Hampshire branch location. The following chart provides a visual description of the
Main and Limited data collections:
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
11
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
The Stop Loss Data collection shall include data for all policies with Coverage Type
Code = “STL” (as defined in Attachment B-1). No policies with Coverage Type Code
= “STL” should be included in either the Main Data collection or the Limited Data
collection.
The tabulation of information and issues below should be considered separately
within each of the three data collections.
Tabulation of Information
A reporting record shall include unique combinations of the coverage category,
market type (market category code), and benefit structure. Any difference in
benefit structure due to covered benefits specified as “exception variables,” member
liabilities (i.e. copay, deductible, and coinsurance) or any other variable listed in
this report, means that data needs to be reported on a separate row.
Carriers shall submit one record for each type of coverage and benefit structure.
For example, if a carrier provides multiple employers with only two types of HMO
policies, one an HMO with a low deductible and another with a high deductible, the
carrier shall submit two separate records with the corresponding member months,
premium, and claims.
Carriers issuing stop loss coverage to the employer groups for which they also
administer the self-insured health benefits shall submit one record for each type of
coverage: the self-insured health coverage and the stop loss coverage.
The information described below shall be submitted in the format prescribed in
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
12
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Attachment A. Please note that there are a series of Exception Variables (EV)
listed in Attachment A and in the report template. When the insurance policy
covers the indicated service, leave the field blank in the report submission. When
the insurance policy does not offer coverage for the indicated service at all, submit
“NC” in the appropriate field for that policy. If the insurance policy generally covers
the indicated service but the coverage does not meet the coverage definition
provided in Attachment A, submit “DM” in the appropriate field for that policy. Do
NOT substitute field requirements with “Y”, “N”, “NA”, or anything not specified in
the reporting requirement. Do not change column headings. Do not insert or delete
columns.
Tabulation Issues – Multiple Carriers
The Department recognizes that there may be instances where more than one
carrier is involved in administrating policies for a common employer in
conjunction with that employer’s health insurance benefits. For self-insured
plans, both the carrier administering the plan and the carrier writing the stop
loss coverage shall submit a supplemental report.
The following guidelines clarify, in those instances when more than one carrier is
involved with providing coverage to a single employer, which carrier has the
responsibility to include the coverage in its tabulation.
• Data on reinsurance policies, insurance policies written by a carrier to
another carrier, shall not be tabulated and shall not be included with
the required supplemental report.
• Stop-loss insurance, or group excess loss insurance issued to an
employer or other group, shall be reported by the writing carrier. It is
considered direct insurance and carriers writing such coverage shall be
responsible for submitting information on their written policies.
• In the event that the entity administering coverage is different than
the carrier writing coverage, the writing carrier shall be responsible for
submitting the required information. Carriers writing risks shall be
responsible for submitting information on policies covering the
underwritten risks. Entities responsible only for policy administration
shall not be responsible for tabulating data on policies that they
administer when such coverage is written on another carrier’s paper
and reported by that carrier.
• TPAs or carriers administering an employer-sponsored health
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
13
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
insurance benefit plan shall submit records for all self-insured plans
that they administer. TPAs must file a supplemental report for this
type of activity regardless of whether a stop-loss writer is filing
information for the same employer.
• Similarly, a stop loss carrier must file the information prescribed in
this section regardless of whether a TPA, or some other carrier, is
filing a supplemental report for the same employer.
Tabulation Issues – Geographic Location
The policy geographic location code shall be based on the specific business location
of the policyholders; where the policy is sitused (refer to “Situs” in the Definitions
section of this bulletin). For NH residents working at a branch location in NH, the
policyholder location may be out of state. All codes are specified in Attachment D.
All policies included in the Main Data collection should be NH policies with a
geographic location code other than ‘Y’, while all policies included in the Limited
Data collection should be non-NH policies with a geographic location code of ‘Y’.
Policies included in the Stop Loss Data collection should use the appropriate code
from Attachment D, whether ‘Y’ or another value.
Carriers shall use a county code of ‘Z’ to identify NH locations for which there is no
county code mapped to the NH zip code that is stored by the carrier. Whenever a
code of ‘Z’ is used, the carrier shall include a note record specifying the NH zip code
for which there is no county code match.
Acceptable Methods for Estimating Data
In certain instances, a carrier may not have the information it needs to tabulate
data as prescribed. For example, a carrier writing stop loss, or group excess
insurance may not know who the employer’s employees are. Carriers and TPAs
shall provide data at the most detailed level at which the carrier or TPA keeps the
data. For this example, the number of certificate holders, e.g. employees, and the
number of covered lives shall be estimated based on data used by the carrier to
price the business.
Where carriers use estimation methods, the carrier shall include, as part of its data
submission, an explanation in the notes section to explain why estimation methods
were necessary and the methods used to generate the estimates. The NHID
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
14
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
reserves the right to approve or disapprove the method of estimation.
Acceptable Methods for Submission All data submissions will be processed electronically. Carriers are required to
submit the supplemental data in an MS Excel Workbook format provided by the
Department. The Department created a template that is available for download from
the Department’s website.
The template is the Excel file called Supplemental Data Request Template
2016.xlsm. This file shall be used as a template for creating new spreadsheets.
After downloading this file to a local directory in Windows Explorer, right click on
the downloaded file, and select New. This will create a new workbook file based on
the downloaded template. Do not change the worksheet names or column headings
in the template.
All carriers shall create a workbook using the Supplemental Data Request Excel
Template. Carriers shall name the workbook SIR<cocode>_2016.xls based on
the carrier NAIC code. The naming is important for processing purposes.
After data have been input into the worksheet, please use the button on the
“Transmittal” sheet to check that data fields are formatted correctly and only valid
codes have been reported. Any possibly invalid entries will be highlighted and
should be reviewed and, if necessary, corrected prior to submission. Note that
macros must be enabled in order to run the validity check.
All supplemental templates shall be transmitted via electronic mail to the
Insurance Department. Supplemental Data Request templates shall be
simultaneously electronically mailed to the following two email address:
All such correspondence shall use the following text as the subject header, “ATTN:
NHID Supplemental Report 2016”.
Data Reconciliation
To assist carriers in ensuring consistent reporting practices and that the data
submission is reasonable in relation to the reporting requirements, we have
included additional data reconciliation checks. These data checks compare the data
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
15
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
in this submission to data the carrier reported to the NH Comprehensive Health
Information System (CHIS). Instructions and a template for the data
reconciliations can be found on the “Data Reconciliation” sheet in the Supplemental
Report Excel Template. These reconciliations should be performed prior to the
template being submitted to the Department. While the data submission is not
required to reconcile exactly to the other data sources, explanations of differences
must be provided. Please note that comparisons are made only on the data that
overlap between the reports and should reconcile.
If the CHIS data are not available for use in the comparison, the reason must be
provided on the “Notes” sheet in the Supplemental Data Request Excel Template.
Confidentiality
(a) Each company or person from whom information is sought shall provide the
required information to the commissioner.
(b) The Supplemental Data Request data filed by each health carrier shall be
subject to the New Hampshire Right-to-Know law, RSA 91-A. The Right-to-Know
law shall not be deemed to limit the commissioner's authority to use or disclose such
information which the commissioner in the exercise of his/her duty may deem
appropriate pursuant to RSA 400-A:25.
Any questions on the Supplemental Data Request should be directed to Don
Gorman at Gorman Actuarial, Inc. at [email protected].
Attachment A Supplemental Data Request Specifications
Transmittal
There shall be one worksheet in the workbook named ‘Transmittal.” The worksheet
shall contain the following information.
Field Name Description
Company Code Please be sure to enter as text, e.g. for
01234, type ‘01234 in the cell.
Company Name
Reporting Year Four-digit years for the calendar year from
which this report is based.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
16
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Fiscal Year End Date Use MMDD format. For most companies,
this will be 1231.
Contact Person First Name
Contact Person Last Name
Contact Person Mailing Address
Line One
Contact Person Mailing Address
Line Two
Contact Person Mailing City
Contact Person Mailing 2-Letter
State Abbreviation
Contact Person Mailing Zip Code Enter as text (see Company Code above).
Contact Person Direct Voice
Phone Number
If there is an extension, use the character
‘x’ to separate the phone number from the
extension.
Contact Person e-mail address
Identify all subcontractors and
the services that are
subcontracted.
List all subcontractors and the services
that are subcontracted (e.g. prescription
drugs, mental health/substance abuse).
Are all claims for subcontracted
services included in the
submitted data?
Input “Y” for yes, “N” for no. If “N” please
explain what has been included and/or
excluded.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
17
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Main Data Collection The main data collection worksheet shall be called ‘”Main Data” and shall include
data for policies with a NH situs with the exception of those with coverage type
“STL”. The first row of the Main Data worksheet shall contain the labels listed in
the Variable column below. Subsequent rows shall contain the data prescribed. The
data must be provided at the most specific level in order to accurately recognize the
health plan product characteristics and benefit differences, including those based on
member/patient liabilities.
All numeric data, such as member months and dollar totals must be reported on an
accrual basis in a number format. Dates of coverage, premium collected, claims
paid, and all determinations are based on a calendar year. Since determinations are
made based on the calendar year, the data will include any changes in enrolled
membership, premiums, and claims, such as when a group renews mid-year. Data
specific to individual groups will be summarized and combined with all other groups
with similar benefit characteristics (as determined by the variables listed below).
Variable Description
Coverage Type Three digit character code for coverage type: UND, ASW,
ASO, STN, or MCD as fully described in Attachment B-1.
Plan Type Three digit character code for plan type: HMO, POS, PPO,
EPO, or FFS as fully described in Attachment B-2.
Market Category
Code
Three or four digit character code for identifying employer
size, student insurance policies, or blanket insurance.
Employer size is based on the number of eligible employees4
in the group. For qualified association trusts, assign the
group size applicable to each subgroup within the
association. Codes are in Attachment C.
Policyholder
Geographic Location
One digit county codes assigned based on the location of the
policyholder (not member). Codes are in Attachment D.
4 “Eligible Employee” shall have the same meaning as defined in INS 4100, specifically INS 4103.03 (g) for the Small
Group market, INS 4104.03 (i) for the Large Group market, and 4105.03 (h) for the Stop Loss market.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
18
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
State, Federal or
Municipal Account
Are the data for the state of NH, federal or municipal
account? Input “S” for State, “F” for federal, “M” for
municipal or “O” for all other accounts.
Qualified
Association Trust
Are the data for a Qualified Association Trust? Input “Y” for
yes, “N” for no.
Professional
Employer
Organization
Are the data for a Professional Employer Organization?
Input “Y” for yes, “N” for no.
HealthFirst This field is obsolete, and may be left blank.
Calendar Year Calendar year the data are reported for.
Number of
Policyholder
Months
Total number of covered months for the policyholder (usually
employer for group policies, or individual for non-group
policies). One policyholder covered for one full year would be
equal to 12. Policy months may not be additive. If an
account has two rows because of the purchase of multiple
products, the policy months will be the same.
Number of
Subscriber Months
Total number of covered months for the subscriber (employee
or individual). One employee covered for one full year would
be equal to 12.
Number of Member
Months
Includes both the total number of covered life months for the
subscriber and for any covered spouses and dependents.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
19
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Total Premium “Premium” shall be calculated as “earned” premium, or the
total amount of premium from policyholders to provide
insurance coverage during the reporting year. Earned
premium = premiums collected + change in due and
uncollected – change in unearned and advance premium.
This should include advance payments of the premium tax
credit. If premium is collected prior to January 1, to provide
insurance coverage during the reported calendar year, than
it must be included in this column. The Commissioner may
approve the use of a reasonable proxy upon the carrier’s
provision of documentation demonstrating that the use of the
same does not materially distort the carrier’s data
submission.
For self-insured business, TPAs and carriers shall calculate
earned premium by aggregating the total funds collected
from contracted accounts to provide for all claims and
expenses associated with the administration of the
employer’s benefit plan. These funds include provisions for
claims (net of stop-loss recoveries), administration, premium
for stop-loss coverage (for policies with Coverage Type of
“ASW”), profit margins, commissions, wellness programs,
network fees, and disease management programs.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
20
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Total Claims Total claims incurred on behalf of the covered members in
the reporting class during the calendar year for which the
supplemental report is being made. Note that total claims
are reported on an accrual basis for calendar year. All
claims with a date of service during the reporting year are
to be included as claims paid in this field. If necessary,
actuarial completion factors should be used to estimate
incurred claims and should be based on when the carrier
extracts the data for the Supplemental Report.
Incurred claims shall include:
• claims incurred during the reporting period and paid
prior to the report date
• claims incurred and reported during the reporting
period but unpaid prior to the report date
• claims incurred but not reported during the
reporting period.
• other payments and credits such as capitation,
incentive payments, prescription drug rebates, etc.
For insured business, incurred claims should be consistent
with what is reported in Part 1, Line 5 of the NAIC
Supplemental Health Care Exhibit, allowing for variances
due to any restatement of unpaid claims with additional paid
claim runout.
For self-insured business, TPAs and carriers shall calculate
incurred claims on a similar basis with the following
additions:
• incurred claims shall be net of any stop-loss
recoveries.
• include amounts paid for stop-loss coverage.
The amount reported in this field should be the sum of the
following three fields: (1) Claims Incurred and Paid, (2)
Claims Incurred and Unpaid, and (3) Other Payments and
Credits.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
21
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Claims Incurred
and Paid
Includes claims incurred during the reporting period and
paid prior to when the carrier extracts the data for the
Supplemental Report.
Claims Incurred
and Unpaid
Claims incurred during the reporting period and unpaid
(payable) as of the data extract including both (1) claims
reported but still payable (sometimes referred to as in course
of settlement)and (2) claims not reported and payable
(sometimes referred to as incurred but not reported).
Other Payments
and Credits
Includes other payments made such as capitation, incentive
payments, etc. or credits received such as prescription drug
rebates which are included in medical expense as reported
for the carrier’s Statement of Revenue and Expenses, or its
equivalent, which is a required component of the annual
statement filing. For policies with Coverage Type = “ASW”,
TPAs and carriers should report any stop-loss recoveries and
stop-loss premiums in this field.
Member
Responsibility
For the claims included in the “Total Claims” field, report
the total known amount (that is, those associated with
incurred and paid claims) of deductibles, coinsurance
amounts, and copayments or any balance-billing for which
the member is responsible. This field should not include
amounts for denied claims or claims covered by another
payer due to coordination of benefits.
Plan ID This is the 17 character HIOS Plan ID (Standard
component plus Variant). This field may not be available
for all market segments; input “N/A” where not available.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
22
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Plan Code This identifier should be the same Plan Code or Name used
in the NH Individual and Small Group rate filings, which is
described in the Requirements for Accident and Health
Insurance Rate Submissions User Manual (found on the
NHID website5). This field may not be available for all
market segments; input “N/A” where not available.
Policy Form
Number Policy Form Number associated with this health plan
coverage.
Exchange and
Network Indicator Describe the network and whether the coverage is On
Exchange or Off Exchange. Please choose one of the
following four choices:
On Exchange, Standard Network (ES)
Off Exchange, Standard Network (NS)
On Exchange, Limited Network (EL)
Off Exchange, Limited Network (NL)
Grandfathered or
Transitional Policy
Indicator
Is this health coverage plan Grandfathered per the ACA
definition or considered a Grandmother/Transitional
policy? Input “G” for Grandfathered plans, “T” for
Transitional/Grandmothered policies, or “N” for plans that
are neither Grandfathered nor Transitional.
HDHP Does the policy meet the IRS definition of a HDHP? Input
“Y” for yes, “N” for no.
Is this health
coverage plan open?
Is this health coverage plan open or closed? Input “Y” if
open, “N” for closed.
In closed blocks, only existing contracts are allowed to
renew. Benefit options in closed blocks are not marketed or
being sold to new customers. If at any time in the reporting
year a block becomes closed, it should be considered closed
for the purpose of this report.
5 http://www.nh.gov/insurance/legal/documents/user_guide-v5.pdf or updated version, if
available
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
23
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Is this a new health
coverage plan?
Was this health coverage plan new in the calendar year for
which the supplemental report is being made? Input “Y” for
yes, “N” for no.
A new health coverage plan is a benefit design that is being
offered/marketed for the first time in this reporting year.
Does Deductible
apply to all Medical
Services?
Input “Y” for yes, “N” for no, or “N/A” if there is no
medical deductible.
Since many plans will be covering preventative office visits
at 100%, consider only other types of medical services when
responding to this question.
Is there an
integrated Medical
and Pharmacy
Deductible?
Input “Y” for yes, “N” for no, or “N/A” if there is no medical
deductible.
Are Preventive
Services Covered
100%?
Input “Y” for yes, “N” for no.
Preventive Services refers to the preventive services as
defined and required in the Affordable Care Act as of the
reporting year.
Does this health
coverage plan
provide coverage for
MH/SA?
Input “Y” for yes, “N” for no.
Does this health
coverage plan have
a Tiered Network
component?
Input “Y” for yes, “N” for no.
A Tiered Network is defined as varying levels of cost sharing
based on different networks of providers set up to cover a
broad range of services that are considered in-network. An
arrangement that is specific to a limited number of services,
such as gastric bypass or transplants, would not be considered
a Tiered Network for the purposes of this report.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
24
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
PCP Office Visit
Copay
Dollar amount of the PCP office visit copay for services
within network. If this service has no cost sharing, input 0
(zero). If this service does not have a copay but is subject to
the deductible and/or coinsurance, input “D/C”. For Tiered
Network HMO products, provide cost sharing for most
utilized tier.
Specialist Office
Visit Copay
Dollar amount of the Specialist office visit copay for services
within network. If this service has no cost sharing, input 0
(zero). If this service does not have a copay but is subject to
the deductible and/or coinsurance, input “D/C”. For Tiered
Network HMO products, provide cost sharing for most
utilized tier.
ED Copay Dollar amount of the Emergency Department copay for
services within network. If this service has no cost sharing,
input 0 (zero). If this service does not have a copay but is
subject to the deductible and/or coinsurance, input “D/C”.
For Tiered Network HMO products, provide cost sharing for
most utilized tier.
Outpatient Surgery
Copay
Dollar amount of the Outpatient Surgery copay for services within network. If this service has no cost sharing, input 0
(zero). If this service does not have a copay but is subject to
the deductible and/or coinsurance, input “D/C”. For Tiered
Network HMO products, provide cost sharing for most
utilized tier.
Inpatient Copay Dollar amount of the Inpatient copay for services within
network. If this service has no cost sharing, input 0 (zero). If
this service does not have a copay but is subject to the
deductible and/or coinsurance, input “D/C”. For Tiered
Network HMO products, provide cost sharing for most
utilized tier.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
25
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
In-Network Single
Deductible
Dollar amount of the in-network, single tier type policy
deductible. For Tiered Network HMO products, provide cost
sharing for most utilized tier. For FFS products, provide the
overall cost sharing information.
This is the Medical deductible for policies with a Medical
only deductible, and the integrated Medical and Pharmacy
deductible for policies that have an integrated Medical and
Pharmacy deductible as reported in the data field “Is there
an integrated Medical and Pharmacy Deductible?”
In-Network
Coinsurance
Percentage figure of total plan and patient liability that the
member is responsible for paying. For example, if the insurer
pays 80% and the member pays 20%, a value of 0.20 should
be reported. If the plan has more than one co-insurance, use
the highest level for services within network. For Tiered
Network HMO products, provide cost sharing for most utilized tier. For FFS products, provide the overall cost
sharing information. This value shall be in numeric decimal
format with a value between 0 and 1.
In-Network Single
OOP Max
Dollar amount of the maximum out of pocket expenses for
services within network for a single tier type policy. The out
of pocket maximum should include any deductibles, where
applicable. For Tiered Network HMO products, provide cost
sharing for most utilized tier. For FFS products, provide the
overall cost sharing information. If there is no maximum,
enter: 9,999,999.
Retail Pharmacy
Single Deductible
Generic
Dollar amount of the single tier type policy deductible for
generic prescriptions dispensed at an in-network retail
pharmacy. If there is no deductible, input 0 (zero). For
polices with an integrated Medical and Pharmacy
deductible, input 0 (zero) in this field, report the integrated
deductible in the “In-Network Single Deductible” field, and
input “Y” in the “Is there an integrated Medical and
Pharmacy Deductible?” field.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
26
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Retail Pharmacy
Single Deductible
Brand Formulary
Dollar amount of the single tier type policy deductible for
brand prescriptions on the formulary dispensed at an in-
network retail pharmacy. If there is no deductible, input 0
(zero). For polices with an integrated Medical and
Pharmacy deductible, input 0 (zero) in this field, report
the integrated deductible in the “In-Network Single
Deductible” field, and input “Y” in the “Is there an
integrated Medical and Pharmacy Deductible?” field.
Retail Pharmacy
Single Deductible
Brand Non-
Formulary
Dollar amount of the single tier type policy deductible for
brand prescriptions not on the formulary dispensed at an in-
network retail pharmacy. If there is no deductible, input 0
(zero). For polices with an integrated Medical and
Pharmacy deductible, input 0 (zero) in this field, report the
integrated deductible in the “In-Network Single Deductible”
field, and input “Y” in the “Is there an integrated Medical
and Pharmacy Deductible?” field.
Retail Pharmacy
Single Deductible
Specialty
Dollar amount of the single tier type policy deductible for
specialty prescriptions dispensed at an in-network retail
pharmacy. If there is no deductible, input 0 (zero). For
polices with an integrated Medical and Pharmacy
deductible, input 0 (zero) in this field, report the integrated
deductible in the “In-Network Single Deductible” field, and
input “Y” in the “Is there an integrated Medical and
Pharmacy Deductible?” field.
Retail Pharmacy
Copay Generic
Dollar amount of the copay for 30-day supply generic
prescriptions dispensed at an in-network retail pharmacy. If
this service does not have a copay, input 0 (zero).
Retail Pharmacy
Copay Brand
Formulary
Dollar amount of the copay for 30-day supply brand
prescriptions on the formulary dispensed at an in-network
retail pharmacy. If this service does not have a copay, input
0 (zero).
Retail Pharmacy
Copay Brand Non-
Formulary
Dollar amount of the copay for 30-day supply brand
prescriptions not on the formulary dispensed at an in-
network retail pharmacy. If this service does not have a
copay, input 0 (zero).
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
27
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Retail Pharmacy
Copay Specialty
Dollar amount of the copay for 30-day supply specialty
prescriptions dispensed at an in-network retail pharmacy. If
this service does not have a copay, input 0 (zero).
Actuarial Value “Actuarial Value” – For the purposes of this report, the
Actuarial Value will be the Minimum Value measure as
outlined in Section 1302 (d)(2)(C) of the Affordable Care Act.
Beginning in 2014, insurers and employers or unions with
self-insured plans must report information to the IRS for
each individual covered under a health insurance plan that
provides minimum coverage. This information will be used by
the IRS to determine whether individuals who purchase
insurance on the exchanges will be eligible for a premium tax
credit. The minimum value is defined as the percentage of
the total allowed costs of benefits provided under a group
health plan or health insurance coverage. In accordance with
the HHS regulations there are several options for
determining the Minimum Value:
• Determine Minimum Value figure using publically
available Minimum Value Calculator excel model
tool which can be downloaded from the following
website: http://www.cms.gov/cciio/resources/regulations-
and-guidance/index.html . The Department of Health
and Human Services has published guidance titled
“Minimum Value Calculator Methodology” which is
also available on the website. This guidance provides
a detailed description of the data underlying the MV
Calculator and the calculator’s methodology • Determine Minimum Value figure through any safe
harbor established by HHS and IRS.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
28
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
• If the plan design is incompatible with the
Minimum Value Calculator or Safe Harbor Plan,
the Minimum Value figure may be determined
through an actuarial certification from a member of
the American Academy of Actuaries.
For each set of reported coverage options, e.g. each benefit
plan, the carrier shall include on the Supplemental Report
the Minimum Value figure calculated in accordance to one
of the three options mentioned above. The Minimum Value
Calculator can be used for a wide variety of health plan
designs; however, it is possible some benefit plan designs
may not fit into the calculator. In circumstances where this
is the case, and the minimum value from the safe harbor or
actuarial certification is not readily available, it is
recommended that a reasonable estimate based on
comparison to similar plan designs be reported in the
Supplemental Report. If a method other than the
Minimum Value Calculator is used, the alternate
method that was used must be disclosed and described in
the notes section of the report submittal form.
Please do not provide figures based on the Actuarial
Value Calculator. The Actuarial Value Calculator
uses different population base and different continuance
tables than the Minimum Value Calculator. The
results from the two calculators will be slightly different.
For the purposes of this report and stable comparison
across coverage segments and carriers, the Minimum
Value Calculator must be used.
This minimum value as described above is the “actuarial
value.”
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
29
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
The remaining variables are Exception Variables
(EV). Enter “NC” if the policy does not cover this
service. Enter “DM” if the policy generally covers this
service, but does not meet the exact service
description. Leave blank if this is a covered item.
Ambulance Service EV
Audiology Screening
for Newborns
EV - Includes: covered for one screening and one confirming
screening.
Blood and Blood
Products
EV - Includes: fees associated with the collection or donation
of blood or blood products, all cost recovery expenses for
blood, blood derivatives, components, biologics, and serums to
include autologous services and albumin.
Case Management
Program
EV - Includes: available for medically complex and costly
services.
Chiropractic
Services
EV
Durable Medical
Equipment (DME)
EV - Includes: nebulizers, peak flow meters, and diabetes
glucose monitoring equipment.
Emergency Room EV
Family Planning
Services
EV – full range of services including: counseling services and
patient education; examination and treatment by medical
professionals; laboratory examinations and tests; and
medically approved methods, procedures, pharmaceutical
supplies and devices to prevent conception. This category
does not include infertility services; these services are covered
under a separate benefit category.
Habilitative
Services
EV - Includes: coverage for children 0-19 years of age for
treatment of congenital and genetic birth defects.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
30
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Hearing Aids EV - Includes: coverage and services as defined by NH State
Law; including hearing aid for each hearing-impaired ear
every 60 months.
Home Health Care EV - Includes: coverage as an alternative to otherwise
covered services in a hospital or other related institution.
Hospice EV - Includes: coverage same as Medicare, including
nursing care, medical social services, physicians' services,
counseling services, short-term inpatient care, medical
appliances and supplies, home health aide services, physical
therapy, occupational therapy, speech-language pathology,
and other items and services.
Hospitalization EV - Includes: unlimited (includes detoxification)
Infertility Services EV - Includes: coverage for services obtained after diagnosis
of infertility including all non-experimental infertility
procedures including, but not limited to, artificial
insemination and intrauterine insemination, in vitro
fertilization and embryo transfer, gamete intrafallopian
transfer, sperm and/or egg procurement and processing,
intracytoplasmic sperm injection, zygote intrafallopian
transfer, assisted hatching, cryopreservation of eggs, and
infertility-related drugs.
Does not include any experimental infertility procedure,
surrogacy, or reversal of voluntary sterilization.
Medical Food EV - Includes: for persons with metabolic disorders when
ordered by a health care practitioner qualified to provide
diagnosis or treatment in the field of metabolic disorders
Mental Health and
Substance Abuse
EV - Includes: when delivered through a managed care
system for 60 inpatient days with partial hospitalization
traded on a 2 to 1 basis and unlimited outpatient visits
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
31
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Nutritional
Services
EV - Includes: six visits per year for cardiovascular disease,
diabetes, malnutrition, cancer, cerebral vascular disease, or
kidney disease.
Outpatient
Hospital Services &
Surgery
EV
Outpatient
Laboratory &
Diagnostic Services
EV
Outpatient Short-
Term
Rehabilitative
Services
EV - Includes: physical therapy, speech therapy, and
occupational therapy
Pediatric Dental
Services
EV – Includes: coverage for diagnostic, preventative services
minor and major restorative services, implants and
orthodontia. Minor restorative services include but aren’t
limited to filings, crowns and oral surgery for impacted
teeth. Major restorative services include inlays, root canals
and fixed prosthesis.
Leave blank when covered under the medical policy. Input
“NC” if the medical policy does not cover these services.
Pediatric Vision
Services
EV – Includes: but is not limited to, diagnostic services,
frames & prescription lenses or contract lenses.
Leave blank when covered under the medical policy. Input
“NC” if the medical policy does not cover these services.
Pregnancy and
Maternity
EV
Prescription Drugs
(Rx)
EV - Includes: prescriptions available on an open formulary
with coverage of at least the generic drug equivalent amount
when the brand name drug is prescribed.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
32
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Preventive Services EV - Includes: preventive services as defined and required
in the Affordable Care Act as of the reporting year.
Skilled Nursing
Facility
EV - Includes: 100 days as an alternative to otherwise
covered care in a hospital or other related institution.
Transplants EV - Includes: for bone marrow, cornea, kidney, liver, lung,
heart, pancreas, and pancreas/kidney transplants.
Well Child &
Immunization
Benefits
EV - Includes: for children 0 – 13 years of age.
Limited Data Collection
The limited data collection worksheet shall be called ‘”Limited Data” and shall
include data for policies with a non-NH situs with the exception of those with
coverage type “STL”. The first row of the Limited Data worksheet shall contain the
labels listed in the Variable column below. Subsequent rows shall contain the data
prescribed. The data must be provided at the most specific level in order to
accurately recognize the health plan product characteristics.
All numeric data, such as member months and dollar totals must be reported on an
accrual basis in a number format. Dates of coverage, claims paid, and all
determinations are based on a calendar year. Since determinations are made based
on the calendar year, the data will include any changes in enrolled membership,
premiums, and claims, such as when a group renews mid-year. Data specific to
individual groups will be summarized and combined with all other groups with
similar characteristics (as determined by the variables listed below).
Variable Description
Coverage Type Three digit character code for coverage type: UND, ASW,
ASO, STN, or MCD as fully described in Attachment B-1.
Plan Type Three digit character code for plan type: HMO, POS, PPO,
EPO, or FFS as fully described in Attachment B-2.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
33
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Market Category
Code
Three or four digit character code for identifying employer
size, student insurance policies, or blanket insurance.
Employer size is based on the number of eligible employees6
in the group. For qualified association trusts, assign the
group size applicable to each subgroup within the
association. Codes are in Attachment C.
Policyholder
Geographic
Location
One digit county codes assigned based on the location of the
policyholder (not member). Codes are in Attachment D.
Only policies with a Policyholder Geographic Location code
of “Y” (a non-NH sitused policy) should be reported on the
“Limited Data” tab.
Qualified
Association Trust
Are the data for a Qualified Association Trust? Input “Y” for
yes, “N” for no.
Professional
Employer
Organization
Are the data for a Professional Employer Organization?
Input “Y” for yes, “N” for no.
HealthFirst This field is obsolete, and may be left blank.
State, Federal or
Municipal Account
Are the data for the state of NH, federal or municipal
account? Input “S” for State, “F” for federal, “M” for
municipal or “O” for all other accounts.
Number of
Policyholder
Months
Total number of covered months for the policyholder (usually
employer for group policies, or individual for non-group
policies). One policyholder covered for one full year would be
equal to 12. Policy months may not be additive. If an
account has two rows because of the purchase of multiple
products, the policy months will be the same.
6 “Eligible Employee” shall have the same meaning as defined in INS 4100, specifically INS 4103.03 (g) for the Small
Group market, INS 4104.03 (i) for the Large Group market, and 4105.03 (h) for the Stop Loss market.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
34
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Number of
Subscriber Months
Total number of covered months for the subscriber (employee
or individual). One employee covered for one full year would
be equal to 12.
Number of Member
Months
Includes both the total number of covered life months for the
subscriber and for any covered spouses and dependents.
Calendar Year Calendar year the data are reported for.
Total Claims Total claims incurred on behalf of the covered members in
the reporting class during the calendar year for which the
supplemental report is being made. Note that total claims
are reported on an accrual basis for calendar year. All
claims with a date of service during the reporting year are to
be included as claims paid in this field. If necessary,
actuarial completion factors should be used to estimate
incurred claims and should be based on when the carrier
extracts the data for the Supplemental Report.
Incurred claims shall include:
• claims incurred during the reporting period and paid
prior to the report date
• claims incurred and reported during the reporting
period but unpaid prior to the report date
• claims incurred but not reported during the reporting
period.
• other payments and credits such as capitation,
incentive payments, prescription drug rebates, etc.
For self-insured business, TPAs and carriers shall calculate
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
35
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
incurred claims on a similar basis with the following
additions:
• incurred claims shall be net of any stop-loss
recoveries.
• include amounts paid for stop-loss coverage
The amount reported in this field should be the sum of the
following three fields: (1) Claims Incurred and Paid, (2) Claims
Incurred and Unpaid, and (3) Other Payments and Credits.
Claims Incurred
and Paid
Includes claims incurred during the reporting period and
paid prior to when the carrier extracts the data for the
Supplemental Report.
Claims Incurred
and Unpaid
Claims incurred during the reporting period and unpaid
(payable) as of the data extract including both (1) claims
reported but still payable (sometimes referred to as in course
of settlement)and (2) claims not reported and payable
(sometimes referred to as incurred but not reported).
Other Payments
and Credits
Includes other payments made such as capitation, incentive payments, etc. or credits received such as prescription drug
rebates which are included in medical expense as reported for
the carrier’s Statement of Revenue and Expenses, or its
equivalent, which is a required component of the annual
statement filing. For policies with Coverage Type = “ASW”,
TPAs and carriers should report any stop-loss recoveries and
stop-loss premiums in this field.
Member
Responsibility
For the claims included in the “Total Claims” field, report the
total known amount (that is, those associated with incurred and
paid claims) of deductibles, coinsurance amounts, and
copayments or any balance-billing for which the member is
responsible. This field should not include amounts for denied
claims or claims covered by another payer due to
coordination of benefits.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
36
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Stop Loss Data Collection
The stop loss data collection worksheet shall be called “Stop Loss Data” and shall
include all data related to “STL” coverage type (both NH and non-NH situs). The
first row of the Stop Loss Data worksheet shall contain the labels listed in the
Variable column below. Subsequent rows shall contain the data prescribed. The
data must be provided at the most specific level in order to accurately recognize the
product characteristics.
All numeric data, such as member months and dollar totals must be reported on an
accrual basis in a number format. Dates of coverage, claims paid, and all
determinations are based on a calendar year. Since determinations are made based
on the calendar year, the data will include any changes in enrolled membership,
premiums, and claims, such as when a group renews mid-year. Data specific to
individual groups will be summarized and combined with all other groups with
similar characteristics (as determined by the variables listed below).
Variable Description
Coverage Type Three digit character code for coverage type as fully
described in Attachment B-1. All policies in the Stop Loss
Data collection should have coverage type = “STL”.
Plan Type Three digit character code for plan type of the underlying
health plan: HMO, POS, PPO, EPO, or FFS as fully
described in Attachment B-2. If plan type of the underlying
health plan is not available, input “N/A”.
Market Category
Code
Three or four digit character code for identifying employer
size, student insurance policies, or blanket insurance.
Employer size is based on the number of eligible employees7
in the group. For qualified association trusts, assign the
group size applicable to each subgroup within the
association. Codes are in Attachment C.
Policyholder
Geographic
Location
One digit county codes assigned based on the location of the
policyholder (not member). Codes are in Attachment D.
7 “Eligible Employee” shall have the same meaning as defined in INS 4100, specifically INS 4103.03 (g) for the Small
Group market, INS 4104.03 (i) for the Large Group market, and 4105.03 (h) for the Stop Loss market.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
37
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Qualified
Association Trust
Are the data for a Qualified Association Trust? Input “Y” for
yes, “N” for no.
Professional
Employer
Organization
Are the data for a Professional Employer Organization?
Input “Y” for yes, “N” for no.
State, Federal or
Municipal Account
Are the data for the state of NH, federal or municipal
account? Input “S” for State, “F” for federal, “M” for
municipal or “O” for all other accounts.
Number of
Policyholder
Months
Total number of covered months for the policyholder (usually
employer for group policies, or individual for non-group
policies). One policyholder covered for one full year would be
equal to 12. Policy months may not be additive. If an
account has two rows because of the purchase of multiple
products, the policy months will be the same.
Number of
Subscriber Months
Total number of covered months for the subscriber (employee
or individual). One employee covered for one full year would
be equal to 12.
Number of Member
Months
Includes both the total number of covered life months for the
subscriber and for any covered spouses and dependents.
Calendar Year Calendar year the data are reported for.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
38
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Specific Premium Premium for specific stop loss coverage provided in the
reported calendar year.
“Premium” shall be calculated as “earned” premium, or the
total amount of premium from policyholders to provide
insurance coverage during the reporting year. Earned
premium = premiums collected + change in due and
uncollected – change in unearned and advance premium.
This should include advance payments of the premium tax
credit. If premium is collected prior to January 1, to provide
insurance coverage during the reported calendar year, then
it must be included in this column. The Commissioner may
approve the use of a reasonable proxy upon the carrier’s
provision of documentation demonstrating that the use of the
same does not materially distort the carrier’s data
submission.
Specific Claims Total specific stop loss claims incurred during the calendar
year for which the supplemental report is being made. Note
that claims are reported on an accrual basis for calendar
year. If necessary, actuarial completion factors should be
used to estimate incurred claims and should be based on
when the carrier extracts the data for the Supplemental
Report.
Incurred claims shall include:
• claims incurred during the reporting period and paid
prior to the report date
• claims incurred and reported during the reporting
period but unpaid prior to the report date
• claims incurred but not reported during the reporting
period.
Specific
Attachment Point
Dollar amount of claim threshold level for an individual at
which specific stop loss coverage begins.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
39
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Specific %
Reimbursable
Portion of the claims above the attachment point to be
reimbursed by the specific stop loss coverage. This value
shall be in numeric decimal format with a value between 0
and 1. For example, if 80% of claims over the attachment
point are covered by stop loss insurance, enter 0.80.
Specific
Reimbursement
Maximum
Dollar amount of the maximum amount reimbursable for a
specific stop loss claim. If there is no maximum, enter:
9,999,999.
Aggregate
Premium
Premium for aggregate stop loss coverage provided in the
reported calendar year.
“Premium” shall be calculated as “earned” premium, or the
total amount of premium from policyholders to provide
insurance coverage during the reporting year. Earned
premium = premiums collected + change in due and
uncollected – change in unearned and advance premium.
This should include advance payments of the premium tax
credit. If premium is collected prior to January 1, to provide
insurance coverage during the reported calendar year, then
it must be included in this column. The Commissioner may
approve the use of a reasonable proxy upon the carrier’s
provision of documentation demonstrating that the use of the
same does not materially distort the carrier’s data
submission.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
40
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Aggregate Claims Total aggregate stop loss claims incurred during the
calendar year for which the supplemental report is being
made. Note that claims are reported on an accrual basis for
calendar year. If necessary, actuarial completion factors
should be used to estimate incurred claims and should be
based on when the carrier extracts the data for the
Supplemental Report.
Incurred claims shall include:
• claims incurred during the reporting period and paid
prior to the report date
• claims incurred and reported during the reporting
period but unpaid prior to the report date
• claims incurred but not reported during the reporting
period.
Aggregate
Attachment Point
Multiple of expected claims at which aggregate stop loss
coverage begins. This value shall be in numeric decimal
format with a value greater than 1. For example, if the
attachment point is 110% of expected claims, input 1.10.
Aggregate %
Reimbursable
Portion of the claims above the attachment point to be
reimbursed by the aggregate stop loss coverage. This value
shall be in numeric decimal format with a value between 0
and 1. For example, if 80% of claims over the attachment
point are covered by stop loss insurance, enter 0.80.
Aggregate
Reimbursement
Maximum
Dollar amount of the maximum amount reimbursable under
aggregate coverage. If there is no maximum, enter:
9,999,999.
Medical Do Medical claims apply toward the stop loss limit? Input
“Y” if yes, “N” if no.
Pharmacy Do Pharmacy claims apply toward the stop loss limit? Input
“Y” if yes, “N” if no.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
41
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Dental Do Dental claims apply toward the stop loss limit? Input “Y”
if yes, “N” if no.
Vision Do Vision claims apply toward the stop loss limit? Input “Y”
if yes, “N” if no.
Disability Do Disability claims apply toward the stop loss limit? Input
“Y” if yes, “N” if no.
Data Checks
The carrier/TPA shall perform the validation check provided within the
Supplemental Data Request Template prior to submitting the data to the New
Hampshire Insurance Department. The template contains an automated process, or
data validation tool, for checking the validity of some, but not all data on the ‘Main
Data’, ‘Limited Data’ and ‘Stop Loss Data’ tabs. The data validation tool checks
specific columns for specific values and should not be substituted for an extensive
data review using the provided instructional information. This process is only a tool
to facilitate the overall data validation process.
The ‘Transmittal’ tab contains a button labeled ‘Click to Run Data Validation
Checks’ in the C19:G21 cell range. This button is provided to facilitate the
verification process of data input into the ‘Main Data’, ‘Limited Data’ and ‘Stop Loss
Data’ tabs. Please note that the data validation process can be run multiple times.
When pressed, the workbook will scan the ‘Main Data’, ‘Limited Data’ and ‘Stop
Loss Data’ tabs and provide a brief summary on the ‘Transmittal’ tab of invalid and
potentially invalid data. Additionally, the scan will highlight invalid or potentially
invalid fields within the data tabs themselves. Finally, pressing the button scans
the ‘Main Data’ and ‘Limited Data’ tabs and populates the Supplemental Report
data in the exhibits on the ‘Data Reconciliation’ tab. To assist the carriers in
populating the fields correctly, instructions for all reported fields have been
included in tabs within the Supplemental Report Template. If there are any
discrepancies between the instructions in the template and this bulletin, the
bulletin instructions supersede the template.
The ‘Transmittal’ tab contains several reports on invalid or potentially invalid data
arranged in several blocks. Column C displays counts for the ‘Main Data’, column I
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
42
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
displays counts for the ‘Limited Data’ and column O displays counts for the ‘Stop
Loss Data’.
The first set of blocks below the validation button displays an overview of potential
errors:
• Row 25 reports a count of ‘Null’, or empty, cells where null cells are not
expected.
• Row 26 reports a count of potentially invalid data, not including nulls.
The second set of blocks contains specifics on potential issues involving
Coverage Type, Plan Type, and Market Category Code:
• Rows 31, 32 and 33 contain a count of invalid Coverage Type, Plan Type and
Market Category Codes for both data tabs. These should be counted as
invalid and fixed according to the respective tabs in the instruction section of
the workbook.
The third set of blocks contains additional specifics on potential issues relating to
the remaining data fields:
• Row 35 checks that appropriate rules are followed regarding the ‘Policyholder
Geographic Location’ column of the two data tabs. Any possible
inconsistencies are highlighted in yellow on the respective data tabs.
• Rows 37, 39, 41 and 43 are specific to the ‘Main Data’ tab.
• Row 37 checks for an appropriate In-Network Coinsurance level. A cell
highlighted in yellow may potentially be acceptable, but the ‘Coinsurance’
Instruction tab should be referenced to make sure the meaning is fully
understood.
• Row 39 checks for an appropriate Actuarial Value. A number higher than 1.0
will be highlighted in yellow as it is unexpected and should be double
checked.
• Row 41 checks for an In-Network Deductible inconsistency based on IRS
rules for High Deductible Health Plans. Please see the ‘Deductible’
Instruction tab for more details.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
43
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
• Row 43 checks for an In-Network Out of Pocket Maximum inconsistency
based on IRS rules for High Deductible Health Plans. Please see the ‘OOP
Max’ Instruction tab for more details.
• Each of the checks in Rows 35 through 43 has additional notes provided at
the bottom of the ‘Transmittal’ tab.
Please note that while the data validation tool can provide the user with potential
errors, it is possible that not all errors or warnings are invalid, and it is also
possible that the tool overlooks actual errors. The tool should be used in addition to
a reasonable data validation process, and not as the only method of validating data.
For technical issues you may encounter when performing the validation step, please
refer to the ‘Technical Troubleshooting’ tab in the workbook.
Data Reconciliation
The “Data Reconciliation” sheet compares the data reported in the Supplemental
Data Request to data submitted for the NH Comprehensive Health Information
System (CHIS). The data from the Supplemental Data Request is pulled from both
the “Main Data” collection and the “Limited Data” collection worksheets.
Carriers/TPAs shall populate the highlighted cells with the requested data as
submitted to NH CHIS. Any differences greater than the percentage shown in the
template must be explained in the space provided.
Values from the Supplemental Data Request data submission will be populated
by pressing the button on the “Transmittal” tab. There is also a button labeled
“Click to Populate Report Exhibits Below” located on the “Data Reconciliation”
tab in cells E3 and E4. Clicking this button will recalculate the values from the
Supplemental Data Request data in both sections of the report on the “Data
Reconciliation” tab.
If the CHIS data are not available for use in the comparison, the reason must be
provided on the “Notes” sheet in the Supplemental Data Request Excel Template.
Summary Tables
The Worksheet “Summary Tables” contains a summary table for each of the three
data submittal Worksheets: Main Data, Limited Data and Stop Loss Data. The
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
44
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
carrier must review the total amounts for Member Months, Premium, Claims,
Member Responsibility and subsequent per member per month (PMPM) amounts.
These amounts are broken out by Coverage Type and Market Category Code. The
carrier must check these summary amounts for accuracy prior to submitting the
data.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
45
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Attachment B-1 Coverage Type Codes
All coverage type character codes are exactly three characters. Carriers shall use
the codes listed herein.
For self-funded plans that are administered by a third-party administrator, where
the employer has purchased stop-loss, or group excess, insurance coverage, carriers
shall use a code of ASW.
For self-funded plans that are administered by a third-party administrator, where
the employer has not purchased stop-loss, or group excess insurance coverage,
carriers shall use a code of ASO.
For stop-loss, or group excess loss insurance, carriers shall use STL.
For short-term non-renewable health insurance, as defined per RSA 415:5 III,
carriers shall use a code of STN.
Insurance sold to protect the health of Medicaid eligible individuals, generally
purchased by state governments, shall not be considered major medical expense.
Carriers shall report such business as other than major medical expense coverage
and use the Medicaid related insurance code of MCD.
For plans underwritten by the carrier and not referenced above, use code UND.
For any other plan, use OTH. Carriers using this code shall provide an explanation
on the Notes worksheet.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
46
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Attachment B-2 Plan Type Codes
All plan type character codes are exactly three characters. Carriers shall use the
codes listed herein, and the codes should reflect how plans are licensed.
For indemnity-type plans, with no managed care features, carriers shall use a code
of FFS, (Fee-for-Service).
For Preferred Provider Organization type plans, carriers shall use a code of PPO.
For Exclusive Provider Organization type plans, carriers shall use a code of EPO.
For Point of Service type plans, carriers shall use a code of POS.
For Health Maintenance Organizations managed care plans, carriers shall use a
code of HMO.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
47
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Attachment C Market Category Codes
All market category character codes are described below. Carriers shall use the
codes listed herein. For policies sold and issued through a qualified association
trust, carriers shall assign the code based on the employee count of the employer
sub-group.
“Eligible Employee” shall have the same meaning as defined in INS 4100,
specifically INS 4103.03 (g) for the Small Group market, INS 4104.03 (i) for the
Large Group market, and 4105.03 (h) for the Stop Loss market.
For policies sold and issued directly to individuals, other than those sold on a
franchise basis, as defined per RSA 415:19, or as group conversion policies,
previously required per RSA 415:18, VII (a), carriers shall use a code of IND.
For policies sold and issued directly to individuals on a franchise basis, as defined
per RSA 415:19, carriers shall use a code of FCH.
For policies sold and issued directly to individuals as group conversion policies, as
previously required per RSA 415:18, VII (a), carriers shall use a code of GCV.
For policies sold and issued directly to employers having exactly one eligible
employee, carriers shall use a code of GS1.
For policies sold and issued directly to employers having between two and nine
eligible employees, carriers shall use a code of GS2.
For policies sold and issued directly to employers having between 10 and 25 eligible
employees, carriers shall use a code of GS3.
For policies sold and issued directly to employers having between 26 and 50 eligible
employees, carriers shall use a code of GS4.
For policies sold and issued directly to employers having between 51 and 99 eligible
employees, carriers shall use a code of GLG1.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
48
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
For policies sold and issued directly to employers having 100 or more eligible
employees, carriers shall use a code of GLG2.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
49
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
For policies sold and issued as blanket health insurance policies to a common
carrier, carriers shall use a code of BLC.
For policies sold and issued as blanket health insurance policies to an employer,
carriers shall use a code of BLE.
For policies sold and issued as blanket health insurance policies to a volunteer fire
department, first aid, or other such volunteer group, carriers shall use a code of
BLV.
For policies sold and issued as blanket health insurance policies to a sports team or
a camp, carriers shall use a code of BLS.
For policies sold and issued as blanket health insurance policies to a travel agency,
or other organization that provides travel-related services, carriers shall use a code
of BLT.
For policies sold and issued as blanket health insurance policies to a university or
college, carriers shall use a code of BLU.
For policies sold and issued as student major medical expense large group coverage
to enrolled students at an accredited college, university, or other educational
institution, carriers shall use a code of SLG.
For policies sold and issued as group short term student health insurance, carriers
shall use a code of STS.
For policies sold and issued as student major medical group health insurance,
carriers shall use code SMG.
For policies sold and issued as student group health insurance that is not major
medical coverage, carriers shall use a code of SNM.
For policies sold and issued as student individual major medical health insurance,
carriers shall use a code of SIM.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
50
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
For policies sold and issued as student individual health insurance that is not major
medical coverage, carriers shall use a code of SIN.
For policies sold to other types of entities, carriers shall use a code of OTH.
Carriers using this market code shall provide an explanation on the Notes
worksheet.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
51
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Attachment D Policyholder Geographic Location
County County Code
Belknap B
Carroll L
Cheshire E
Coos S
Grafton G
Hillsborough H
Merrimack M
Rockingham R
Strafford D
Sullivan N
Non-NH Y
NH; unable to
match zip code to
county code8
Z
Note: The above codes should be assigned based on the location of the policyholder
(not the member). Non-NH policyholder data (with County Code of “Y”) shall be
reported on the Limited Data tab and all other data shall be reported on the Main
Data tab.
8 Zip code(s) must be provided to the NHID.
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
52
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Attachment E Translation Table – Zip Codes to NH County Codes
From Through County
03031 Hillsborough
03032 Rockingham
03033 Hillsborough
03034 03042 Rockingham
03043 Hillsborough
03044 Rockingham
03045 Hillsborough
03046 Merrimack
03047 03052 Hillsborough
03053 Rockingham
03054 03071 Hillsborough
03073 Rockingham
03076 Hillsborough
03077 03079 Rockingham
03082 03086 Hillsborough
03087 Rockingham
03101 03105 Hillsborough
03106 Merrimack
03107 03111 Hillsborough
03215 Grafton
03216 Merrimack
03217 Grafton
03218 03220 Belknap
03221 Merrimack
03222 03223 Grafton
03224 Merrimack
03225 03226 Belknap
03227 Carroll
03229 03231 Merrimack
03232 Grafton
03233 03235 Merrimack
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
53
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
From Through County
03237 Belknap
03238 03241 Grafton
03242 03243 Merrimack
03244 Hillsborough
03245 Grafton
03246 03249 Belknap
03251 Grafton
03252 03253 Belknap
03254 Carroll
03255 Merrimack
03256 Belknap
03257 03258 Merrimack
03259 Carroll
03260 Merrimack
03261 Rockingham
03262 Grafton
03263 Merrimack
03264 03266 Grafton
03268 Merrimack
03269 Belknap
03272 03273 Merrimack
03274 Grafton
03275 Merrimack
03276 Belknap
03278 Merrimack
03279 Grafton
03280 Sullivan
03281 Hillsborough
03282 Grafton
03284 Sullivan
03287 Merrimack
03289 Belknap
03290 03291 Rockingham
03293 Grafton
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
54
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
From Through County
03298 03299 Belknap
03301 03307 Merrimack
03431 03435 Cheshire
03440 Hillsborough
03441 Cheshire
03442 Hillsborough
03443 03448 Cheshire
03449 Hillsborough
03450 03457 Cheshire
03458 Hillsborough
03461 03467 Cheshire
03468 Hillsborough
03469 03470 Cheshire
03561 Grafton
03570 Coos
03574 Grafton
03575 03579 Coos
03580 Grafton
03581 03584 Coos
03585 Grafton
03587 03598 Coos
03601 Sullivan
03602 Cheshire
03603 Sullivan
03604 Cheshire
03605 03607 Sullivan
03608 03609 Cheshire
03740 03741 Grafton
03743 03746 Sullivan
03748 03750 Grafton
03751 03754 Sullivan
03755 03769 Grafton
03770 Sullivan
03771 Grafton
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
55
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
From Through County
03772 03773 Sullivan
03774 03780 Grafton
03781 03782 Sullivan
03784 03785 Grafton
03801 03804 Rockingham
03805 Strafford
03809 03810 Belknap
03811 Rockingham
03812 03814 Carroll
03815 Strafford
03816 03818 Carroll
03819 Rockingham
03820 03825 Strafford
03826 03827 Rockingham
03830 03832 Carroll
03833 Rockingham
03835 Strafford
03836 Carroll
03837 Belknap
03838 Carroll
03839 Strafford
03840 03844 Rockingham
03845 03847 Carroll
03848 Rockingham
03849 03850 Carroll
03851 03852 Strafford
03853 Carroll
03854 Rockingham
03855 Strafford
03856 03859 Rockingham
03860 Carroll
03862 Rockingham
03864 Carroll
03865 Rockingham
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
56
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
From Through County
03866 03869 Strafford
03870 03871 Rockingham
03872 Carroll
03873 03874 Rockingham
03875 Carroll
03878 Strafford
03882 03883 Carroll
03884 Strafford
03885 Rockingham
03886 Carroll
03887 Carroll
03890 03897 Carroll
The State of New Hampshire
Insurance Department 21 South Fruit Street, Suite 14
Concord NH 03301
57
Roger A. Sevigny Alex Feldvebel
Commissioner Deputy Commissioner
Attachment F Notes – Explanations as required in Instructions
Included in the Excel workbook is a worksheet for carriers/TPAs to include notes on
any explanations as required in the instructions. For example, if data are submitted
with Coverage Type Code of “OTH” an explanation of what this represents should
be included on the “Notes” sheet in the data submission file. Another example is if
a carrier/TPA used a method other than the Minimum Value Calculator for the
“actuarial value,” the reason and method used must be described in the notes
section.
Carriers/TPAs should include notes on any membership not included in the report
submission, and the approximate total membership on December 31 of the calendar
year included in the report filing. These may include covered lives for additional
lines of business that do not meet the supplemental report criteria but that are
covered as risks in some form by the carrier/TPA. Examples include dental
insurance, Medicare supplemental insurance, or pharmacy benefit management
services when not provided in conjunction with health insurance benefits.
The notes section of the submission template can also be used to include additional
information relevant to the report submission.